Every finding on record at Carepartners HHA, LLLP

Observed in Record Review. In 1 of 1 patient records reviewed, for extended prognosis, it was noted by the surveyor that for RRDC#1 the Notice of Medicare Non-coverage (NOMNC) was provided to the patient to sign on the day of discharge, not two days before the determined date of discharge as required. Findings were discussed and verified with the RN Clinical Team Manager, The Accreditation Readiness Specialist, the Hospice Educator, and the Hospice Director.

Observed in Record Review. In 2 of 19 patient records reviewed, it was noted by the nurse surveyor that the comprehensive assessment was not completed within five calendar days of the election of the hospice benefit. For RRNHV#1, the initial bereavement risk assessment was completed over two months late. For RRHV#3, the social worker completed her initial assessment and the bereavement risk assessment one day late. Findings were discussed and verified with the RN Clinical Team Manager, the Accreditation Readiness Specialist, the Hospice Educator, and the Hospice Director.

Observed in Record Review. In 1 of 19 patient records reviewed, it was noted by the nurse surveyor that the initial bereavement assessment was not completed as part of the comprehensive assessment. For RRNHV#4, the social worker did not complete the initial bereavement assessment at the time she completed her initial social work assessment as was agency practice. Patient was admitted two weeks ago and does not have a documented initial bereavement assessment. Finding was discussed and verified with the RN Clinical Team Manager, the Accreditation Readiness Specialist, the Hospice Educator, and the Hospice Director.

Observed in Record Review. In 14 of 14 patient records reviewed, for all active records, the nurse surveyor noted that the goals were not measurable or individualized. For example, “Patient/caregiver verbalizes/demonstrates understanding of management of diabetes to prevent diabetic event”, and “Patient will demonstrate reduction or relief of cardiopulmonary symptoms including energy conservation measures, pacing activities, and prn oxygen”. There were no short-term goals at start of care to address issues of immediate needs such as understanding medication management, symptom management, pain management, or safety. Additionally, time frames for completion were either at the end of the certification period or not at all. Findings were discussed and verified with the RN Clinical Team Manager, the Accreditation Readiness Specialist, the Hospice Educator, and the Hospice Director.

Observed in Record Review. In 2 of 14 patient records reviewed, it was noted by the nurse surveyor that orders were not complete. For RRHV#3, an oxygen concentrator and back up cylinder were obtained for the patient for shortness of breath after the admission. However, a doctor’s order was not obtained. For RRNHV#2, the patient’s foley catheter had been removed, then after a week due to bladder retention, the patient needed it re-inserted, however, a physician order was not obtained. Findings were discussed and verified with the RN Clinical Team Manager, the Accreditation Readiness Specialist, the Hospice Educator, and the Hospice Director.

Observed in Record Review. In 8 of 8 patient records reviewed, for patients with a hospice aide, it was noted by the nurse surveyor that the hospice aide care plans did not include the information necessary for the hospice aide to effectively care for the patients. For RRHV#2, the patient had broken her foot, yet the hospice aide care plan had not been revised to indicate the change in weight bearing. For RRHV#3, the patient was on continuous oxygen and the care plan did not address whether the oxygen could be removed for the bed bath. For RRNHV#2, the patient had a foley catheter, it was removed, then reinserted, yet the hospice aide care plan had not been revised to educate the hospice aide on when to notify the skilled nurse. Additionally, none of the hospice aide care plans included instructions to notify the skilled nurse if there were changes in the patient’s condition or any skin breakdown. Findings were discussed and verified with the RN Clinical Team Manager, the Accreditation Readiness Specialist, the Hospice Educator, and the Hospice Director.

Observed in Record Review. In 2 of 8 patient records reviewed, with a hospice aide, it was noted by the nurse surveyor that Hospice Aide Supervisory visits were not documented every fourteen days as required. For RRNHV#3, the nurse did not document a Hospice Aide Supervisory visit for 21 days and for RRNHV#8, the Hospice Aide Supervisory visits were documented sixteen days apart. Findings were discussed and verified with the RN Clinical Team Manager, the Accreditation Readiness Specialist, the Hospice Educator, and the Hospice Director.

Observed in Record Review. In 1 of 14 patient records reviewed, it was noted by the nurse surveyor that the patient record was inaccurate. For RRNHV#8, at the time of the IDG meeting due to malfunction of the EMR software, the RN and the Hospice physician were unable to complete their documentation to update the comprehensive assessment. Findings were discussed and verified with the RN Clinical Team Manager, the Accreditation Readiness Specialist, the Hospice Educator, and the Hospice Director who also provided a sign-in sheet and an attached list of the patients discussed at the IDG to verify that the plan of care had been discussed.

Observed in Patient Home. In 2 of 4 home visits conducted, it was noted by the nurse surveyor that the medication profile was inaccurate. During RRHV#1, it was noted during the medication reconciliation by the skilled nurse, that the patient was no longer taking the ordered K2 Plus D3 but was taking K- Tab 20 Meq extended Release (also on the medication list). The K2 Plus had not been taken off of the patient’s medication profile. Additionally, the patient had stopped applying the ordered Triamcinolone Acetonide 0.025% topical cream and was now applying over the counter Hydrocortisone cream to her itchy skin. The Triamcinolone Acetonide had not been discontinued and the Prednisone had not been added. Findings were verified by the Registered Nurse Manager who was present during the visit. . For RRHV#4, it was noted during the visit with the Medical Social Worker and conversation with the patient’s son/primary caregiver that the patient was taking one Baby ASA, a Zinc supplement, and Vitamin D3 daily, additionally, the son was administering Trazadone 100mg daily (what the patient was taking prior to going to the nursing home), not the 150 mg she was discharged home on. The medication profile did not reflect these changes. Finding was verified by the PRN RN who was present during the visit.

Observed in Record Review. In 9 of 15 patient records reviewed, the organization failed to assess and reassess its patients. During record review for RR #1, RR#3, RR#8 and RR#9, the hospice nurse surveyor observed the patient's had active wounds but the organizational policy of documenting measurements weekly was not being followed. For example in RR#3, the patient had two skin cancer lesions previously being measured and documented on weekly, as required by policy. But were not healed and weekly documentation stopped 4/2022. In RR#8 the patient had wound measurement documented at SOC 5/31/22 but no further measurements were documented and patient passed away 6/24/22. During record review for RR#5, RR#6, RR#7 and RR#8 and HV#2, the hospice nurse surveyor observed the initial bereavement assessment was not completed. And in BR#1, the initial bereavement assessment was completed late. This was discussed and reviewed with the Hospice Leadership Team.

Observed in Record Review. In 13 of 13 patient records reviewed, the organization failed to plan the patient's care. During record review for all records, the hospice nurse surveyor observed the written plan of care did not contain goals needed for all services required or individual time frames to meet those goals. For example in HV#1, all SW goals were to be met by the same date of 10/02 and there were no goals for spiritual care needs. In RR#1, all goals were to be met by the same date of 10/22 and nothing on the plan of care for new wound. And for RR#2, the patient had multiple visits to the hospital and the ER but it was not addressed in the plan of care. After discussion with the Hospice Leadership team, the surveyor reviewed multiple locations for problem/goals/interventions to be updated with the team to address difficulties with their EMR. This was discussed and reviewed with the Hospice Leadership Team.

Observed in Record Review. In 13 of 13 patient records reviewed, the organization failed to plan the patient's care. During record review for all records, the hospice nurse surveyor observed there was no documentation of progress towards goals and missed opportunity for updates to the plan of care for changes to the patient comprehensive assessment. In all records reviewed, there was no documentation of progress towards goals. In RR#1 there was no documentation to the plan of care for a new wound. And in RR#2, there was no documentation of recent hospitalization or ER use on the plan of care. This was discussed and reviewed with the Hospice Leadership Team.

Observed in Patient Home. In 2 of 3 home visits conducted, the organization failed to implement infection prevention and control activities when cleaning and performing disinfection of reusable medical supplies before placing back in the bag. During HV#1 and HV#2, the hospice nurse surveyor observed that device or disinfectant manufacturer instructions for use were not followed but patient was not likely placed at risk for BBP transmission as evidenced by: Staff did not follow contact time (wet time) as specified by the manufacturer. The organizational policy states to follow manufacturer guidelines and the Sani- Wipes state a 2 minute wet time for disinfection. This was discussed and reviewed with the Hospice Leadership Team.

Observed in Record Review. In 5 of 15 patient records reviewed, the organization failed to plan the patient's care. During record review for HV#2, RR#5, RR#6, RR#7 and RR#8, the hospice nurse surveyor observed no documentation of a care plan for the bereaved. This was discussed and reviewed with the Hospice Leadership Team.